While we attend to the results of alcohol and other drug abuse and addiction, including crime, we spend far too little on preventing crime by addressing this issue. Would using a plague metaphor help us create a broad-based approach to preventing the crime that results from substance use disorder?

What Does Recovery Look Like?

Gene Gilchrist

 Our hope has been to demystify substance use, abuse and addiction and to provide hopeful, helpful guides for the individual suffering from the disease as well as their loved ones. Over several articles we have tried to be consistent, accessible, informative and hopeful.

Too often we fail to treat this topic as a disease state as recognized by the American Medical Association for nearly seventy years. Too often discussions of alcohol and drug abuse revolve around moralistic tones and depressing outcomes. Recovery too often becomes an arduous, life-long task of perpetual guardedness.  Hopefully, we are getting past those perceptions.

Let us take a moment to discuss recovery. Historically, the odds have been long. Even with the advent of Alcoholics Anonymous and its various offspring, best estimates are that less than 10% of people with substance use disorder ever attain recovery when defined as one year of continuing abstinence. That definition of “success” is being expanded these days, and the outcomes are getting closer to those of other, chronic diseases such as type 2 diabetes and cardiopulmonary disease. Regardless, there is much room for hope.

The Substance Abuse and Mental Health Services Administration (SAMHSA) 2022 Annual Survey¹ states that more than 20 million Americans self-report that they are in recovery. Although a “self-report,” this is promising in that it means that those 20 million people identify with their substance use issue. At the same time, the definition of recovery is expanded including those who relapse from alcohol estimated at 90% in four years and opioids at 78% in one year.

Further, that same report suggests that only about fourteen percent remain abstinent in recovery for more than ten years (yes, the estimates remain difficult to obtain due in part to continuing concerns over anonymity). Promoters of harm reduction and other approaches are discussing treatment and recovery in terms other than abstinence, and this is more in line with treatment of other chronic diseases such as diabetes. Regardless of how one defines recovery, there are today more available treatments, more options for treatment, and more people are recognizing and attempting to work with their self-diagnosis.

Is there a typical case of recovery? Consider these stories adjusted to protect identity:

·       Mark is in his mid-sixties. Seventeen years ago he drove into a tree while intoxicated. After a night in city jail, and reflecting on previous incidents, he decided that alcohol was not for him any longer and stopped drinking. Today he is a successful designer for marketing materials working independently. He has never been in treatment of any kind

·       Leticia is a fifty-five-year-old woman who lost one of her parents to homicide at a young age. She fell in with “the wrong crowd,” became addicted to drugs, served as a drug “mule”, spent two terms in State corrections before becoming clean and sober in AA/NA. Today she is clean and sober thirty years, married, has two sons and owns her own transitional housing program

 ·       Anne is a thirty-five year old server at an upscale lunch spot. After years of unabated drug use and all the street living that comes with it, she chose treatment over incarceration. After six months in treatment she moved to a half-way house for another six months. She met a man in AA and after a few months of living together he died from a fatal overdose. Though devastated, she redoubled her efforts in her own recovery and is now eight years clean and sober. Her faith is a core component of her recovery

 ·       Alonzo was dropped off at residential treatment program by his family where he spent six months in treatment. After leaving that program he was a regular AA attendee until he found Jesus as his Lord and Savior and was baptized. He married, had children, retired from the uniformed services at age 55 and now has been abstinent for thirty years

·       Robert was orphaned at an early age and moved from foster home to foster parents before age ten. The victim of child abuse, he had been homeless for forty years. At a homeless shelter he encountered AA and also there renewed his faith. Today at age 60 he is studying for the ministry while three years sober

·       Andrew bought and sold marijuana by the pallet. Eventually law enforcement provided him a choice between treatment and jail.  He spent three months in residential treatment, was faithful to NA and has continued clean in NA for thirty-five years. He completed his education through the master’s degree and became an addiction counselor. He is now in his seventies, married, with three children and partially retired from an executive position in State government

·       Susan left her regular after work cocktail spot, got in the wrong car, found the keys in the ignition, and drove someone else’s car into several parked cars. Her lawyer was direct and stern about further representation. She attended AA without ever seeking clinical help. Sober now forty-eight years she retired from a career as a schoolteacher and administrator.

What do these stories have in common other than recovery? Very little and that is the point. These folks are young and not so young, men and women, of different ethnic backgrounds, attached and unattached, professional, white collar, pink collar and blue collar, they are religious and not so religious –they are diverse except that they share a disease and recovery from that disease. We have argued in previous articles that there are many paths to recovery and these stories tell us that the end point of a healthy, happy normal life can be achieved through treating this chronic disease.

It is possible for clinicians to categorize stages of recovery and in the Yale Journal of Biology and Medicine, Steven Melemis reviews those stages and rules for relapse prevention². There are not fixed timelines, but it is commonly held that the Abstinence Stage starts when an individual makes a conscious decision to stop using and usually lasts for 1 to 2 years. The main focus is dealing with cravings and not using. This stage involves acceptance, honesty, developing self-care skills, developing a new lifestyle with family, work and friends, developing new habits and changing a self-image to that of a non-user. Too often these individuals think they have self-control after a time and that is almost always wrong. Patience is key as not everything can be fixed overnight.

Post Acute Withdrawal and Repair stages overlap and continue for several months. Acute withdrawal may take physical form, including very dangerous delirium tremens in the case of alcohol, but is most often emotional in nature. After all, this is a very significant change in lifestyle and not easily done. There are likely to be emotional and physical manifestations that are new to the individual and for which they have undeveloped management skills. This may be helped by Repair which is a very difficult task of amending past relationships and putting one’s life back together. As more people get off the down escalator before hitting bottom, the situation is both easier (as jobs and families remain intact) and more difficult as one faces not just their past actions but the people they impacted regularly.

 In the Repair phase patience is key as not all repairs can happen quickly, and some will never happen. Early in recovery shame, guilt and despair are common feelings that lessen with time. In repairing the damage those feelings return as one faces, honestly, all the behaviors that occurred and all the people who were hurt. The newly recovering feel despondent thinking about the mountain of hurt ahead. However, except in those cases where repair would hurt others, a sincere effort will solidify this newfound freedom from alcohol and drugs and this new life.

Repair also involves rekindling employment and for professionals rekindling careers. Where once a stint in rehab or treatment of some kind, easily spotted by law enforcement searches and employment gaps, was an employment killer, those days are fading. There is still stigma, and one may be on a short leash at first, but the newly recovering generally find employment and revitalized careers. Old or new hobbies are also to be found in this repair stage.

Finally, the Growth Stage involves constructing a new life. In some respects, this is about making up for lost time as the addict’s growth has been delayed while those without addiction moved on in their lives. In other respects, this stage is about developing new skills, new aspects of one’s person that have been there all along or perhaps were choices that were not made during active addiction. To some in recovery this sounds like – “Is that all? A normal life?” Ah, pain has a short memory. Yes, where poor health, mental health treatment, incarceration, loneliness even street living were the norm, now a new lease on life, a new chance, a normal life are joys relished day-to-day as opposed to the rush of that drink or drug.

A word about faith and religion is important here. When AA was first formed and until the advent of the new century America was a country populated mostly by believers. Estimates are that over 90% of Americans believed in a deity and most practiced an organized religion. It was only natural therefore that a belief in “God as we understand Him” would be a part of twelve step regimes. The percentage of American believers is now around 70-75%. For many it is still the case that strong belief and reliance on a higher power is a part of their recovery. As the nation has changed, however, so has the community of people in recovery. Today there are programs for agnostics, atheists, humanists and more where the mention of God is omitted. In many meetings God is included but not as “him.” Fortunately, tolerance has evolved at least in the community of recovery and there are many paths, and most are tolerated. Your faith in a deity or not having one is not a barrier. We encourage you to be tolerant of both of those beliefs.

As noted, relapse remains common. There are those who would say that for many it is inevitable. But no physician would argue that any amount of smoking is better than abstinence for a patient with cardiopulmonary disease. Similarly, while relapse is common it is not required and there is yet scant evidence that the once addicted can return to normal use.

Melemis³ offers five keys to successful, ongoing recovery.

·       Rule 1: Change your life

Recovery is rarely successful just “putting the plug in the jug.” Certainly, there are cases of “white knuckle” recovery where people just hang on, but it is rare and hard. Successful recovery almost always involves change. People may recoil from this and to be sure it is demanding work.

 ·       Rule 2: Be Thoroughly Honest

In the book Alcoholics Anonymous they say, “Half measures availed us nothing. We encourage you to be fearless and rigorous from the start.” This may be nowhere more important than in honesty from day 1. Most people come to recovery having done bad, often shameful, sometimes illegal things. There is no avoiding that. Yet people in recovery report repeatedly that they are no more clean and sober than their secrets. No one needs to know everything, every day, and some things will take time. Some things like dishonesty long forgotten may never be addressed with another. But thorough honesty with self and perhaps with a trusted advisor is --- well – the best policy.

·       Rule 3: Don’t Go It Alone

Very few people recover on their own. Again, certainly, it does happen, but it is rare. Even people who were successful with “the pledge” did so with a minister and God as they understood God. Twelve step programs have been successful for a reason. Clinicians, minsters, trusted colleagues are all available. Take advantage.

·       Rule 4: Practice Self Care:

Physicians, ministers, counselors all are schooled in taking care of themselves as a discipline. It is challenging work and the lines between humans and God, sanity and insanity, life and death are difficult. Recovery is also difficult, at least for many months at the start. Self-care outside of or in conjunction with a program of recovery might include exercise, time with family, attending to a romantic partner, attending to leisure time.

·       Rule 4: Self Care (Again)

Don’t ignore the metaphysical side of self-care. We discussed religion above and if that is not a source of emotional and spiritual self-care there are many outlets. Find one.

·       Rule 5: Don’t Bend the Rules

Far too often the newly recovered want to do things on their terms. Later, others deem themselves cured and want to chart their own path. Would those same people violate building, engineering and construction principles? Would they skip steps in baking bread? Not successfully if they did.

There have now been millions of people in recovery who have established a pattern of recovery. Yes, there are many more paths today and that is a good thing. But one is well advised to keep within those patterns that have worked and to stay the course for the years that it takes. There will be immediate rewards, but that lasting new life will take time.

Too often we still view alcohol and drug abuse as a moral failing. The American Medical Association disagrees. Too often we think about this in terms of the homeless. They suffer but are 1% of the problem. Too often we think of the addict as the exception. There are 40 million of them. Too often we think that recovery is not possible. Once that was nearly the case but today there are 20 million people who consider themselves to be in recovery.

Today there are more resources, more recognition, less morality, less shame. There is never a good time to have a disease. But, like much in medicine today, there is more hope than ever. You can achieve recovery. It is worth the effort.

Finally, we need to let go of thinking of recovery as penance for moral failure and of the process as a minute-by-minute avoidance of relapse.  Writing in the New York Times Review of Books, John Kaag⁴ notes: “There is a pernicious, but widely held belief that turning over a new leaf always involves turning our worlds upside down, that living a happy, well-adjusted life entails acts of monkish discipline or heroic strength. The genre of self-help lives and dies on this fanaticism: we should eat like cave men, scale distant mountains, ingest live charcoal, walk across scalding stones, lift oversized tires, do yoga in a hothouse … in our culture virtuous moderation and prudence rarely sell.”

The goal of recovery is a sober, joyful life.

 1  National Survey on Drug Use and Mental Health; SAMSHA 2023

2  “Relapse Prevention and the Five Rules of Recovery,” Steven Melemis, Yale Journal of Biology and Medicine, September 2015

3  Ibid

4  New York Times, Review of Books, January 29, 2019

We wrote previously that our collective image of alcohol and drug abuse and addiction is in many ways misinformed. Part of that skewed image is that there is a bright line between social and safe alcohol and drug use on the one hand and abusive and addictive use on the other hand. In this article we try to reset that understanding showing that there is a continuum of alcohol and other drug use extending from that occasional misstep to ongoing problematic use to clinical addiction. Given this revised perspective, we might begin to think differently about the point where a change in our individual thinking, a change in public policy, and the need for clinical support might be considered.